center for global development essay
Global Nutrition Institutions: Is There an
Appetite for Change?
By Ruth Levine and Danielle Kuczynski
August 2009
www.cgdev.org/content/publications/detail/1422612
ab s t r a c t
This paper describes the major institutional weaknesses in global nutrition and presents two
recommendations to address the joint problems of incoherence, lack of institutional leaders, and
persistent underfunding. First, within the domain of global health—where a significant part of the
programmatic response rests—current and potential funding agencies at the international level
could create a shared set of principles that lay out expectations for the coordination, coherence,
and collaboration among institutions that currently do or might receive funding for global nutrition
programs. Funders could collaborate to create a strong incentive for UN agencies, the World Bank,
privately funded initiatives, and others to work together to fulfill key functions, including norm-setting,
advocacy, scientific inquiry, program and technical support, capacity-building, and implementation
at the national level. A second priority is for leaders in UN agencies to act on specific opportunities
to elevate the agenda of nutrition security within the work of the UN System High-Level Task Force
for the Global Food Security Crisis, which is stimulating and coordinating a response among the UN
system and international financial institutions.
The Center for Global Development is an independent, nonprofit policy research organization that is
dedicated to reducing global poverty and inequality and to making globalization work for the poor. CGD is
grateful for support of this work from the Bill & Melinda Gates Foundation.
Use and dissemination of this essay is encouraged; however, reproduced copies may not be used for
commercial purposes. Further usage is permitted under the terms of the Creative Commons License. The
views expressed in this paper are those of the author and should not be attributed to the board of directors or
funders of the Center for Global Development.
www.cgdev.org
Ruth Levine and Danielle Kuczynski. 2009. "Global Nutrition Institutions: Is There an Appetite for Change?"
CGD Essay. Washington, D.C.: Center for Global Development.
www.cgdev.org/content/publications/detail/1422612
Global Nutrition Institutions: Is There an Appetite for Change?
Ruth Levine and Danielle Kuczynski
Center for Global Development
SUMMARY
This paper describes the major institutional obstacles to rapid progress and expanded financial
support for international nutrition policies and programs, with primary but not exclusive focus on
those that are linked to the health sector. The work was motivated by the series of articles on
maternal and child undernutrition in The Lancet in 2008, which brought into stark relief the
health consequences of undernutrition and described a dysfunctional international “architecture.”
We interviewed a number of key stakeholders and thinkers in the field of global nutrition,
articulated the major institutional weaknesses, and developed a set of recommendations about
how to address the joint problems of incoherence, persistent underfunding, and lack of
institutional leaders.
No path forward is without risk of failure, but after broad consultation around an earlier draft of
this paper we believe that two sets of actions hold promise. First, within the domain of global
health—where a significant piece of the programmatic response rests—current and potential
funding agencies at the international level could create a shared set of principles that lay out
expectations for the coordination, coherence, and collaboration among institutions that currently
do or might receive funding for global nutrition programs. By clearly stating the desired
characteristics of the institutional arrangements, funders could create a strong incentive for UN
agencies, the World Bank, privately funded initiatives, and others active in the field to work
together to fulfill key functions, including, for example, norm-setting, advocacy, scientific
inquiry, capacity-building, program and technical support, and implementation at national levels.
Second, outside of the health sector per se, opportunities could be systematically sought to give
greater emphasis to “nutrition security” within the several ongoing activities focused on food
security and international agriculture. A priority is to foster a connection between the nutrition
agenda and the work of the UN System High-Level Task Force (HLTF) for the Global Food
1
Security Crisis, which is stimulating and coordinating actions among the UN system and
international financial institutions. Opportunities within the HLTF program of work include
ensuring that technical support on nutrition is made available to countries to better measure,
report on, and develop programmatic responses to acute problems of undernutrition linked to
high food prices; promoting the concept that investments intended to increase productivity of
smallholder farmers should also be used to increase the quality of foods, for example through
biofortified crops; and expanding efforts to establish the global Partnership for Food Security to
encompass a vision of a global Partnership for Food and Nutrition Security.
I.
WHAT’S THE PROBLEM TO SOLVE?
On the face of it, the importance of undernutrition is crystal clear:
•
The global burden of malnutrition is high: Maternal and child undernutrition causes 3.5
million deaths worldwide, and accounts for an estimated 11 percent of total global
Disability Adjusted Life Years (DALYs) and 35 percent of the burden of disease for
children under five years old. About 276,000 children under the age of five die each year
due to severe acute malnutrition and its related causes.1
•
The consequences are long-term and irreversible: poor fetal growth or stunting in the first
two years of life leads to irreversible, long-term physical and cognitive damage; rapid
weight gain in this same group later in life may lead to nutrition-related chronic disease.2
•
Undernutrition is a concentrated crisis, but of low national priority: 80 percent of the
world’s undernourished children live in just 20 countries in the world,3 with South Asia
1
Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera, J, for the Maternal and
Child Undernutrition Study Group, (2008), Maternal and child undernutrition: global and regional exposures and
health consequences. The Lancet, series on Maternal and Child Undernutrition, article 1, 371, 243-60.
2
Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS, for the Maternal and Child
Undernutrition Study Group (2008) Maternal and child undernutrition: consequences for adult health and human
capital. The Lancet, series on Maternal and Child Undernutrition, article 2, 371, 340-57.
2
accounting for almost half of the stunted children globally.4 Of these 20 countries, 13
deem nutrition to be a low priority.5
•
In some parts of the world, the problem is getting worse: while underweight (low weight
for age) is decreasing globally, in some areas, such as Eastern/Southern Africa and
conflict regions of the Middle East/North Africa, underweight is on the rise.6 Given
woefully inadequate social safety nets, recent rapid increases in prices of staple foods are
likely to exacerbate the problem among the most vulnerable.
•
Current crises exacerbate perennial challenges in nutrition security. The potent
combination of upward pressure on food prices, a dramatic and protracted global
economic downturn, and overdependence on non-renewable fuel sources for a range of
inputs for agriculture and food distribution add up to increased vulnerability. Nutrition
insecurity is increasingly related to food insecurity, as families are less able to produce or
buy staple foods and/or they turn to lower-cost—and lower quality—foods.
•
Interventions within the health sector work, but are not being adequately delivered: In 36
focus countries, universal coverage of a package7 of nutrition interventions would reduce
deaths of under-three year olds by a quarter:8 interventions such as universal salt
3
Bryce J, Coitinho D, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P, for the Maternal and Child Undernutrition
Study Group, (2008) Maternal and child undernutrition: effective action at the national level. The Lancet, series on
Maternal and Child Undernutrition, article 4, 371:510-26.
4
Horton S, Alderman H, Rivera JA, Copenhagen Consensus 2008 Challenge Paper, Hunger and Malnutrition.
March 6th 2008.
5
Bryce J, Coitinho D, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P, for the Maternal and Child Undernutrition
Study Group, (2008) Maternal and child undernutrition: effective action at the national level. The Lancet, series on
Maternal and Child Undernutrition, article 4, 371:510-26.
6
Horton S, Alderman H, Rivera JA, Copenhagen Consensus 2008 Challenge Paper, Hunger and Malnutrition.
March 6th 2008.
7
This package includes coverage (at 99 percent of targeted populations) with interventions including balanced
energy protein supplementation, intermittent preventative treatment, multiple micronutrient supplementation in
pregnancy, breastfeeding promotion and support, feeding intervention and support (promotion of complementary
feeding and other supportive strategies), vitamin A (including neonatal in Asia), zinc supplementation, and hygiene
interventions)
8
Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Guigliani E, Haider BA, Kirkwood B, Morris SS, Sachdev
HPS, Shekar M, for the Maternal and Child Undernutrition Study Group (2008), What works? Interventions for
maternal and child undernutrition and survival. The Lancet, series on Maternal and Child Undernutrition, article 3,
371, 417-40.
3
iodization and increased targeted distribution of Vitamin A capsules are highly costeffective, but under-applied.9
These facts alone should be enough to motivate action. So why were basic nutrition investments
by donors in low- and middle-income countries less than $250–300 million per year between
2000 and 2005?10 Why do many of the most affected countries pay little attention to nutrition as
a core public health and social challenge?
This brief report is intended to provide an overview of some of the core obstacles to achieving
significant improvements in nutritional status in poor countries, with a focus on the organization
of and coordination among international actors (public and private donors, technical agencies,
and the corporate sector), particularly those involved in global health (broadly defined). It is
based on a set of structured interviews with knowledgeable individuals (see Annex 1), as well as
a review of documents and materials available on institutional websites. An earlier version of
this paper was presented for feedback at several consultation meetings in Washington and
London.
The focus on the international community is deliberate, and chosen in full recognition that major
improvements will come about only through aligned actions by members of poor households,
their communities, and subnational and national governments, NGOs and businesses. The role
of the international community, while in no way of the greatest importance, is essential.
Members of the international community, including the governments of wealthy countries,
provide technical and financial resources, help to shape the public policy agenda, and influence
prices of food and nutrition-related products, both by design and unintentionally. They can act in
ways that are supportive of the healthiest possible set of nutrition-related actions at the local and
national levels—or they can create inefficiencies and distortions that impede progress.
9
Horton S, Alderman H, Rivera JA, Copenhagen Consensus 2008 Challenge Paper, Hunger and Malnutrition.
March 6th 2008.
10
Morris SS, Cogill B, Uauy R, for the Maternal and Child Undernutrition Study Group (2008), Effective
international action against undernutrition: why has it proven so difficult and what can be done to accelerate
progress? The Lancet, series on Maternal and Child Undernutrition, article 5, 371,608-21.
4
In synthetic form, the report first identifies and describes the key institutional actors, and then
provides an overview of where the core strengths, weaknesses and opportunities currently exist.
A sequence of actions that might serve to systematically address some of the weaknesses is then
outlined. These actions have been discussed in various forms with some of the interviewees, but
do not represent a consensus view. This paper seeks to serve as a point of departure for
discussions among leading actors about whether and how opportunities exist to be more effective
in support of progress toward dramatically improved nutrition outcomes.
II.
A CROWDED FIELD OR AN EMPTY ONE?
The global nutrition “ecosystem” is comprised of many actors. The recent Lancet series on
maternal and child undernutrition identifies at least 14 UN agencies, five international and
regional development banks, five major regional cooperation organizations, more than 20
bilateral aid agencies, at least five major charitable foundations and the 15 or so implementing
agencies created by them, more than 30 international NGOs, at least 35 research centers,
universities, and collaborative members of the Consultative Group on International Agricultural
Research (CGIAR), 12 major nutrition companies, and several hundred academic journals.11
Given the multisectoral nature of nutrition, some of the organizations are primarily associated
with health programs; others are involved in food aid, humanitarian relief, and related areas (see
Table 1 in Annex 2 for a list of the major international organizations examined and discussed in
this paper).
11
Morris SS, Cogill B, Uauy R, for the Maternal and Child Undernutrition Study Group (2008), Effective
international action against undernutrition: why has it proven so difficult and what can be done to accelerate
progress? The Lancet, series on Maternal and Child Undernutrition, article 5, 371,608-21.
5
III.
THE NUTRITION ECOSYSTEM: STRENGTHS, WEAKNESSES, AND
OPPORTUNITIES FOR ACTION
Over many years of activity, the funding, technical, executing, and opinion-shaping institutions
that make up the global nutrition sector have not coalesced into the same policy, funding and
implementation community that exists for some other major global health priorities, such as
immunization or tuberculosis. Rather than constituting a fixed and easily described
“architecture,” the entities involved in nutrition-related policy-setting and programming are more
like an “ecosystem”—a loose collection of entities that are focused largely on their own survival
without an overriding logic or plan behind the division of responsibilities among them. As such,
their roles and activities sometimes overlap, sometimes compete, and often reveal gaps.
In part, the disarray and relative lack of visibility of nutrition is a function of the nature of
undernutrition itself. Poor nutritional status is a risk factor for many poor health outcomes rather
than a direct cause of death and disability, except in extreme cases. Thus, while the loss of life
from measles, diarrheal disease, AIDS, and many other diseases that are on the policy radar
would be reduced by improved nutrition, the interventions that receive resources often are those
that have a clear cause-and-effect relationship with lives saved. In many ways, nutrition is—or
contributes to—“everybody’s problem” but at the same time is “no one’s responsibility.”
There are other reasons for the relatively low visibility of nutrition within the global health and
broader development policy context. In policy circles, there has long been confusion about
whether undernutrition is just lack of sufficient food, which could potentially be ameliorated
through food aid; or whether it is a complex interplay of quality, quantity, and behavior / food
use, which require a combination of interventions and behavior change. When the problem is
defined as lack of food, the many nutrition-related priorities other than food aid get short shrift.
In addition, undernutrition maps closely to poverty, and so requires a genuine commitment on
the part of both national governments and international donors to targeted, pro-poor actions..
While individuals working in international nutrition are often motivated by issues of social
justice and inequality, it can be extremely difficult to mobilize and sustain political leadership
6
around such topics, let alone turn it into action. Moreover, many of the needed nutrition-related
interventions are unlike vaccines and drugs; they are in the domain of social norms and
individual behavior change (e.g., exclusive breastfeeding) or involve relatively basic
technologies, such as vitamin A capsules. These factors all disadvantage nutrition policy and
action compared to many other, more headline-grabbing parts of what has become
conceptualized as the global health agenda. In fact, nutrition does not fit neatly into the “health”
compartment at all, and the multisectoral nature of nutrition’s determinants and consequences
intensify the challenges of identifying champions, strengthening implementing agencies,
expanding funding streams and nurturing knowledge networks.
Despite the nature of the problem and the interventions, much more could be done to effectively
marshal policymaker interest and resources within the domain of global health and beyond.
Currently, the “nutrition ecosystem”—the constellation of institutions at the global and national
levels that fund, study, set priorities, advocate and act—is largely weak and dysfunctional.
While there are some relatively strong elements, most observers agree that international nutrition
is underfunded (relative to both needs and potential), uncoordinated, driven less by evidence than
belief, and marginalized both within the health sector and broader development policy debates.
This section presents a summary of the findings from a set of interviews with key informants
about the strengths and weaknesses of the international nutrition field today. It also summarizes
the features of the current policy environment that provide new opportunities for increasing the
capacity and effectiveness of the nutrition field. Not intended as a definitive statement, this
synthesis is only intended to spark consideration of ways to build on the strengths while pushing
toward filling the many gaps that remain.
Strengths
Several core strengths of international nutrition can serve as building blocks for moving forward:
Nutrition has seen successes. A reasonably good evidence base exists about some of the effective
nutrition interventions, and some large-scale successes have been realized. Successes have been
observed and documented at both the intervention level (Vitamin A, salt iodization) and the
7
country level (Uganda, Mexico, China). In general, success can be attributed to a combination of
technical consensus, good planning and the recognition of broader social determinants and
country specific contexts in planning and implementation. (See box 1 for the example of
Mexico.)
Box 1
How Mexico’s Oportunidades brings research to action*
Until the 1990’s, efforts to reduce malnutrition in Mexico were slow to progress despite focused attention of the
national government. In 1993, the Mexican government spent US$2 million a day on food assistance programsabove internationally recommended standards—with little impact on nutrition indicators.
After a government-led review in 1988 helped to provide data on, among other things, short stature and food
assistance by region, it was recognized that the information would prove valuable for informing nutrition
policies and programs.
The Center for Research in Nutrition and Health (CINyS) of the National Institute of Public Health (INSP) in
Mexico used strategic mission-based research—scientific knowledge generation that can be used to impact
population health—to target those making health and nutrition policies. Oportunidades, Mexico’s
comprehensive national conditional cash transfer program, was designed using this research to cover the needs
of low income families by targeting poverty reduction through child health, food and education. The program
was started by the federal government in 1997 and benefited greatly from collaboration between researchers and
decision makers. Research presented on distribution of need that highlighted the poor design of food assistance
policy at the time allowed the lowest income families to be properly targeted. An effectiveness evaluation
component allows for progress to be tracked and program design to be modified.
Evaluations of Oportunidades show growth impacts on the most vulnerable children exposed to the program for
two years, and a decrease in anemia amongst children exposed for only one year. The program, which now
reaches a target population of approximately 5 million families, has both demonstrated success and provided
rigorous data to support its continuation into the future.
*Pan American Health Organization. Nutrition and an active life: from knowledge to action, Washington, D.C.: PAHO, 2005
•
National planning and engagement is increasing. In Uganda, for instance, coordination
among nutrition actors has improved greatly. A national nutrition plan has been
developed, including expanded micronutrient interventions with the help of USAID and
the creation of productive linkages between public and private sectors through GAIN
(see box 2).
8
•
New partnerships show promise. According to several key informants, coordination of
the international community has increased over the past years from a system that was far
more fragmented. Although there is obvious room for improvement, the changes suggest
that leadership transitions and new partnerships present possible opportunities for
progress, through improved information sharing and the entry of new players and
activities that are less constrained by history and bureaucratic rigidities—including the
Global Alliance for Improved Nutrition and the Micronutrient Initiative (see Box 2).
•
Nutrition has gained policy attention within and outside of global health. Over the past
several years, this increased attention has been marked, for example, by the publication
of the World Bank’s nutrition strategy, Repositioning Nutrition as Central to
Development, and the recent Lancet series on maternal and child undernutrition. While
some civil society organizations have been critical of the poor conceptualization of
programming reflected in the Lancet series—not taking a broader approach to
intervention implementation—the most important result is that a discourse has been
opened through both the global and regional Lancet launches. For instance, in Senegal
the launch helped to bring more support to nutrition nationally. In Ethiopia, the launch
was timed to coincide with the release of a nutrition strategy.
•
Nutrition has also gained a measure of attention within the high-level discussions around
food security, and the food-price and financial crises. Several policy documents related
to the food crises have acknowledged the need to pay attention to food quality as well as
quantity. Donors new to the field, including Ireland, the European Commission, the UK
and foundations, have expressed interest in greater involvement. And, importantly, the
World Bank has over the past several months led a process to develop a Global Action
Plan for Nutrition, which seeks to set out a costed set of programmatic priorities to
address maternal and child undernutrition. All of these represent significant
opportunities.
9
Box 2
Examples of Important Partnerships: GAIN and MI
Global Alliance for Improved Nutrition (GAIN)*: Representing a new way of doing business, GAIN
works to build partnerships between governments and the private sector to deliver nutrition interventions
to populations. They focus on sustainably fortifying staple foods, providing incentives to the private
sector to develop low-cost fortified complementary foods for low-income populations and developing a
global micronutrient procurement fund aimed at improving the supply and reducing the costs of high
quality vitamins and minerals for use in supplementation and fortification programs. Their data shows
success so far:
•
In China, data from 21 sentinel sites showed 1/3 anemia reductions among women and children
who consumed soy sauce fortified with iron. GAIN aims to reduce prevalence of micronutrient
deficiencies by 30 percent
•
GAIN estimates that 99 million people in key coverage groups (women and children) are
consuming fortified foods out of a total 188 million being reached by their projects. GAIN hopes
to put 1 billion individuals on fortified foods, with 500 million being from target populations
•
The cost-per-DALY saved through GAIN projects ranges from US$13 to US$17. The
organizational target is less than US$15 per DALY
•
With a target of $500 million, US$364 million in private sector contributions have been
committed for existing projects through GAIN
Micronutrient Initiative (MI)**: MI is a Canadian-based international not-for-profit organization
dedicated to eliminating vitamin and mineral deficiencies worldwide. It is comprised of a global network
serving more than 70 countries, focusing on Africa, Asia, Latin America, and the Middle East.
MI works either directly or with partners, including governments, food producers, and partner
organizations to develop and implement programs. They employ scientists, nutritionists, policy and
development experts, and on-the-ground practitioners who procure resources, develop policy, technology,
and capacity, and provide technical assistance that includes situation assessment and program design.
In 2007, MI estimated that its programs reached 500 million people worldwide. Looking at vitamin A
alone, MI estimates they delivered 530 million doses to 233 million children, averting 490,000 child
deaths in this year.
*See GAIN website at: http://www.gainhealth.org/. Results reported as of Fiscal Year 2008. Accessed 08/03/09
**See MI website at: http://www.micronutrient.org/home.asp. Accessed 08/03/09; MI annual report 2007-2008
Weaknesses
Fully recognizing that there are strengths to build on, the nutrition ecosystem remains troubled—
about this, virtually all of those who are engaged in the field will agree. Several challenges that
plague the community—poor conceptualization of nutrition as an issue, inter-personal and inter-
10
agency coordination problems, difficulties of implementing a wide range of discrete technical
interventions, and others—impede progress.
The key weaknesses or challenges can be characterized as follows:
•
No institutional leader exists. From an organizational perspective, no clear leader with
adequate resources and a clear mandate emerges in the international community. While
the UN system has the potential to harbor a lead organization, one has failed to emerge
and nutrition does not currently feature prominently on the agenda of any of the relevant
agencies. The UN Standing Committee on Nutrition, which has played an important role
as a forum for discussion of nutrition-related issues and engagement of NGOs with the
UN agencies, is widely observed to have failed to harmonize priorities and practices
across the UN system and more broadly among the nutrition sector, and there is
disagreement about whether SCN has the potential or support from its funders to assert
genuine leadership. No one, for instance, thinks that it has the legitimacy or technical
and political strength to serve the function for nutrition that UNAIDS does in its field.
Two basic problems (among others) are noted: First, there is a long-standing tension
because of different views on the nature of the problem and the corresponding solution:
emergency vs. long-term development, treatment vs. prevention. This is evident in
transatlantic differences in perspective that are played out through international agencies.
While the U.S. approach has tended toward behavioral change to impact nutritional
status, a set of focused technical interventions delivered within the health sector, and food
aid for crisis situations, the European orientation has been more toward understanding
and attempting to act upon the underlying economic and social factors affecting food
security and nutritional status.12 Second, institutions in the official sector have
overlapping mandates, have been unable to agree on and articulate priorities, and have
responded unevenly to a changing environment—including new donors and an increasing
engagement of the private sector, and emerging food and agricultural concerns.
12
Virtually all parties agree that there is value in addressing both food- and nutrition-specific issues and the
underlying social determinants of health, in an integrated model.
11
In short, neither an institutional nor individual leader has emerged above the level of
technical specialists in nutrition to galvanize the nutrition community behind a coherent
set of messages about the importance, urgency and feasibility of addressing nutritionrelated problems in developing countries.
•
Weak linkage to trade, agriculture, and broad development agenda. For organizations
such as the World Bank, which have a very broad agenda, nutrition competes for
attention with an almost uncountable number of “important issues.” A key strategy to get
sustained attention is to link nutrition to more macro-level concerns which are without
question “on the agenda” of the institutions. However, to date there has been only
limited success in doing this, in part because of a lack of evidence but also because
nutrition professionals tend to have difficulty breaking out of highly technical
communication and relating to and communicating with the macroeconomists and other
professional groups that are institutional thought leaders. This particular shortcoming has
come into sharp relief during the recent discussions of the food-price crisis, in which
concerns about the quantity of food has predominated over attention to the quality of
food.
•
Technical communities are fragmented and competitive. To date, technical developments
in the international nutrition field—both in defining and measuring the prevalence of
particular nutrition-related conditions, and in identifying promising “solutions”—have
been driven by relatively small scientific, implementation and advocacy communities.
They have focused on specific health problems, such as deficiency in particular
micronutrients, or key interventions such as breastfeeding promotion, or advocacy targets
such as combating the marketing of breastmilk substitutes in low-income countries.
These communities have evolved their own conceptual frameworks, standards of
evidence, and professional hierarchies, and have tended to interact relatively little—and
often in a competitive mode, given limited funding—with other technical communities.
Related to this, there are several instances in which communities have been formed
around promulgating product-related “solutions” in a somewhat single-minded manner
12
(e.g., staple food fortification, vitamin A capsules, ready-to-use therapeutic food,
“sprinkles”). While there is little doubt about either the potential contribution or the
appeal of these approaches, they have claimed disproportionate importance because there
is so little consensus about a full range or package of nutrition interventions. Funders and
advocates have attached themselves to the limited set of approaches for which there is
reasonable evidence about efficacy and “do-ability.” To the extent that institutions or
leading individuals within them have become identified with particular conditions or
interventions, other institutions and individuals have become alienated. This phenomenon
is compounded and reinforced by the scarcity of financial resources—and at the same
time contributes to a perpetuation of the “starvation diet” for nutrition programs.
•
Public sector institutions have been uncomfortable with engaging the private sector. The
interconnectedness of nutrition and the commercial sector is unquestioned: The main
source of nutrition—food and drink—is primarily provided by a broad range of
commercial enterprises, whether small-scale participants in very local markets or large
multinational corporations. Taken as a whole, the food industry has the capacity for
R&D, supply chains, and market penetration that far exceeds that of the public health
sector, and therefore could contribute tremendously to distribution of nutrition-related
products, if the appropriate incentives were in place and legal and regulatory hurdles
were reduced. Given the influence of the multinational private sector in shaping
production of commodities, there also is tremendous potential for affecting food quality.
At the same time, the practices and products of food manufacturers and distributors are
also “part of the problem” in quite specific ways: the overrefinement of staple grains that
destroys nutrients; the marketing of breastmilk substitutes in communities with poor
water supplies and where breastfeeding confers vital immunologic benefits to infants; the
lack of development of affordable, nutritious foods for populations at greatest risk of
undernutrition; and the production, distribution and marketing of products that contribute
to obesity, hypertension and diabetes. Moreover, in general the commercial sector is by
definition motivated primarily by the profit motive (within the constraints of socially
sanctioned business practices), rather than by a drive to improve health status. Because of
13
this duality, public sector institutions such as UNICEF and WHO have had difficulty
establishing flexible, open working relationships with corporate and other private sector
actors, both in-country and at the global level.
Whether the public sector institutions are or are not willing and able to work in
collaboration with the private sector is an issue of some dispute. Individuals familiar
with key UN agencies assert a genuine willingness to engage constructively with the
commercial sector, both at global and local levels, and an understanding of the potential
benefits of doing so. At the same time, at least some in the private sector express
frustration with a lack of openness and responsiveness to public-private partnerships and
full engagement in discussions of policy and programmatic priorities.
•
International players are disconnected from country priority-setting, policymaking and
implementation systems. Within developing countries with a high burden of
undernutrition, parallel and more extreme institutional weaknesses exist: no clear lead
organization; marginalization of nutrition professionals within the Ministries of Health;
and competition among technical communities for very scarce resources.
Implementation capacity for nutrition programs is extraordinarily weak, suffering from
the low prestige associated with nutrition in Ministries of Health and other agencies, the
limited career mobility, and consequently the shortage of highly motivated, well trained,
and high performing personnel. The entrenched interests associated with food
distribution programs that may not be crucial to good nutrition outcomes are very strong.
In large measure because of these constraints, it has proven difficult to move projects
from small, community-based pilots, to national programs that are relevant across key
population groups. In the absence of coherent national policies and strategies—which is
more the rule than the exception—donor-originated projects tend to be small pilots
without a scale-up plan, focused on their own objectives and modes of operation, and
implemented in a way that is isolated from the health and other social service
infrastructure.
14
Opportunities
Several key opportunities set the stage for progress.
•
Box 3
Leveraging the Lancet. The Lancet
REACH: a Partnership to End Child Hunger and
Undernutrition
series on nutrition has reignited
interests and sparked discussion in
The REACH partnership represents a joint collaboration
between the UN, civil society, and private sector
partners. The REACH partnership includes the lead UN
agencies WFP, FAO, WHO, and UNICEF who are
working with country governments to accelerate
progress on MDG-1, Target 3: halving the proportion of
underweight children under five years old.
a way that could be funneled into
starting a productive dialogue
among actors about how those who
work in nutrition might move
To foster government-led and -owned strategic
partnerships, REACH supports country-level scoping of
the nutrition sector, the development of strategic plans,
costs, and resources mobilization, and tracking and
monitoring of results to represent a new kind of
comprehensive “solution-focused” approach. These
plans are aimed to be multisectoral, taking into account
not only the Ministry of Health, but the role that other
ministries such as finance and agriculture might play.
With the facilitation of locally placed management
consultants from Boston Consulting Group, action
planning and analysis was occurring in two pilot
countries as of 2008: Mauritania and Laos, with further
roll-out scheduled.
forward.
•
Connecting to nutrition-related
crises. The food price shocks of
2007–08 and the severe economic
downturn starting in 2008,
although producing tragic results,
may paradoxically represent an
opportunity. With renewed policy
Source: communications with and materials provided by Boston
Consulting Group
attention to issues of agricultural
productivity, trade in commodities, food aid and in-country subsidy mechanisms, and
local agricultural market development, the nutrition community has a key chance to
draw attention to the importance of quality (not just quantity) of available food.
•
Renewing the UN system. Current leadership of key members of the broad UN
family, including WHO, UNICEF, the World Food Program, and the World Bank,
have signaled more interest in nutrition than was previously seen. An opening may
exist to take advantage of this interest and the relative freedom from “baggage” that
the current leaders of these institutions have. New initiatives like REACH show that
the space for more active collaboration and inclusion of broader actors may already
exist between these agencies (see Box 2).
15
•
Harnessing the resources and innovation of the private sector. The expressed interest
and actions of leading corporate actors such as, Unilever, PepsiCo and Danone have
changed the face of the private sector engagement in nutrition. Agribusiness is also
poised to address some of the nutrition issues related to seeds, which produce more
nutritious crops and increase yield. At least some parts of the multinational and
national private sector are eager to be constructive participants in improved nutrition.
For example, Unilever and World Food Program collaborate on the “Together for
Child Vitality” program, that use the combined procurement, targeting and technical
strengths of the two organizations to deliver school feeding programs. Danone has
developed nutritional products aimed squarely at the “bottom of the pyramid,”
supporting local agricultural production.
Whether through collaboration in fortification programs, development of new,
nutritious products, or sharing knowledge and skills in distribution, marketing and
advocacy for improved policy, the private sector has a significant role to play. In
Uganda, for example, pairing with local industry has helped to grow the private sector
in-country, especially due to the way in which these local partnerships are established
to lead to long-term capacity building. The only limitation is the initial size of local
industry, which with seeding, can grow.
•
Broadening the lens. More than in the recent past, there may now be an opening to
look carefully at the social and economic bases of problems that manifest themselves
as poor health outcomes. With the publication of the report of the Commission on
Social Determinants of Health, greater intellectual space may exist to consider a
broad range of society- and community-level interventions that go far outside of the
narrowly defined health sector—for example, education interventions, job creation,
16
enhancement of women’s status, strengthening of democratic institutions, and
others.13
IV.
VISION AND STRATEGIC ACTIONS
Dramatically improving the health of poor children by reducing the prevalence of undernutrition
requires a long-term vision—and practical “baby steps” to build on the existing opportunities and
address some of the significant weaknesses within and across institutions. One formulation of a
long-term ideal vision for international nutrition might be as follows:
•
At the country level, a broad set of actors have adequate financial, technical and political
resources and capacity to effectively implement large-scale, evidence-based, and
integrated programs to combat undernutrition, with flexibility to learn and adapt to future
challenges.
•
At the global level, a broad set of actors with key technical, financial, and policyinfluence assets act in a coherent, efficient well-coordinated manner to serve countrylevel needs while providing and generating global public goods, with flexibility to
anticipate and work on future issues.
•
At the intersection, complementary actions of global actors that help build knowledge
and capacity within country institutions, working with government counterparts, civil
society, the commercial private sector, and regional organizations in a way that transfers
skills and resources in a sustainable manner.
13
Commission on Social Determinants of Health (2008). Closing the gap in a generation: health equity through
action on the social determinants of health. Final Report of the Commission on Social Determinants of Health.
Geneva, World Health Organization.
17
This vision suggests that at the international level, the organizations most involved in setting the
policy agenda, marshalling the technical inputs, raising and allocating financial resources, and
supporting implementation should have
•
well-defined roles and responsibilities;
•
adequate and sustained financial resources sufficient to support at-scale
implementation;
•
sufficient flexibility to respond to both urgent needs and to adapt as nutrition
problems evolve from the traditional areas of child undernutrition;
•
on-going communication and coordination mechanisms that work smoothly
through respectful and efficient interactions with national leadership; and,
•
checks and balances and a culture of learning to assure accountability and
technical integrity.
The findings from this review suggest that the international nutrition community, and national
counterparts, are now far from this long-term ideal, and instead are faced with major constraints
within and across organizations, technical fragmentation, limited policy voice, and vast shortfalls
in resources, relative to needs. To get “from here to there” will require a sequence of actions,
each with its own timetable and resource requirements.
Strategic Actions
Based on interviews and feedback from an earlier version of this paper, the following actions are
recommended over the next 6–12 months.
1.
Generate a mandate from funders for change, with clear incentives. The current
institutional players have learned how to survive, although in a limited way, within the
existing (dysfunctional) set-up. While there is interest in establishing a more functional
set of institutional relationships, and some progress has been made, additional changes—
that is, compromise and collaboration to agree on roles and responsibilities—imply some
risk, with uncertain benefits relative to the status quo. To induce institutions, like those
in the UN family, to accept that risk will require clear messages from current and
18
potential funders about the benefits—that is, the potential for increased and/or more
flexible resources.
Specifically, bilateral, multilateral and private funders14 with an interest in supporting
improved international nutrition should work together to articulate a clear set of
expectations regarding an institutional framework for nutrition-related policies and
priority-setting at the global level, and support policymaking and programs in countries
with a high burden of childhood undernutrition. If the expectations were met by the
relevant implementing and technical agencies, the funders would then have a greater
ability to deploy additional financial resources for nutrition-related activities—in essence,
the prize for the significant effort of sorting out institutional roles and responsibilities.
For example, funders could indicate that the framework would need to reflect clarity on
which institutions and/or groups of institutions were leading and participating in the
following areas (possibly among others):
•
Creating and disseminating coherent and consistent policy messages, shared
across major institutions
•
Bolstering institutional capacity at the global level in technical domains,
policy and implementation
•
Supporting the development of national nutrition action plans
•
Coordinating across donor and technical organizations in-country
•
Supporting and strengthening institutional capacity at the national and
subnational level in technical domains, policy, implementation and research
•
Establishing a prioritized agenda for research and other types of knowledgegeneration
14
Here we are referring to bilateral donor agencies, such as USAID, CIDA, and DFID; philanthropic foundations
such as the Bill & Melinda Gates Foundation, the Children’s Investment Fund, and the UN Foundation; and
multilateral donors, such as the EC. All of these could reasonably be expected to be able to enter into funding
arrangements with any one of a broad range of organization inside or outside of the UN family. This does not refer
to UN agencies that obtain contributions from member states and allocate them toward programs and policy support.
19
•
Identifying opportunities for and incubating public-private partnerships, along
with the norms (Codes of Conduct, etc.) and the resources for monitoring and
enforcement
•
Taking the lead on various multisectoral policies and actions (healtheducation, health-agriculture, health-social protection, and others)
•
Norm-setting
•
Developing standards and support for data collection and sharing and a
monitoring, evaluation, and operations research framework
Given that funders have diverse priorities and activities—although a common desire for a
more functional institutional architecture—a process would be required to identify and
communicate clear expectations, and to build the support within the funding
organizations for new resources to be devoted to nutrition. This process could occur in
many ways; a five-step process is suggested below as a point of departure:
Step 1—Senior management in funding agencies issue a request for a coherent (and
costed) plan for mobilizing and deploying resources to address nutrition-related health
problems.
Step 2—Senior technical staff at key funding agencies with knowledge of the current
institutional strengths and challenges collaborate through a facilitated process to develop
a draft set of “framework elements” or principles. This process should include
participation in key ways by some knowledgeable but less directly vested participants to
strengthen the openness, transparency, and legitimacy of the discussions.
Step 3—The technical staff, potentially with external reinforcement or promotion by a
high-level political champion, brief senior management within their own organizations
and ensure that the framework elements or principles were acceptable to the organization
and its constituencies. Some iteration back to the broader technical group might be
required.
20
Step 4—Senior management from across the funding agencies meet to discuss and
endorse the framework elements or principles, along with a plan for monitoring and
enforcement at country and global levels.
Step 5—The framework elements or principles are discussed with the senior
management of implementing and technical agencies.
In some sense, this is a heavy-handed approach. It could be interpreted as funders
collectively imposing their will on organizations now badly in need of additional
resources to undertake vital work in support of developing countries. However, there is a
widely felt and intensifying sense that the current institutional arrangements are so badly
lacking in coherence and effectiveness that a dramatic step may be warranted. Simply
the exercise of determining whether it is possible to establish a common set of
expectations among current and potential funders would help to reveal the extent to
which the incoherence is a function of the funding priorities themselves.
2.
Explore opportunities for establishing nutrition as a priority with the UN System HighLevel Task Force on the Global Food Security Crisis. Motivated by the urgency of
addressing the food price crisis and in response to high-level statements by the G-8, the
UN Chief Executives Board established the UN System High-Level Task Force on the
Global Food Security Crisis (HLTF) to coordinate activities among UN agencies and the
international financial institutions. Over the course of a year, the HLTF has been active
in developing a Comprehensive Framework for Action and initiating implementation,
involving both short- term and long-term tracks. While there is only modest attention to
nutrition (food quality and use) issues within the HLTF program of work and reporting to
date, the potential—and probably the openness—exists to integrate nutrition-related
concerns in a more prominent way. In addition, outside of the health sector per se, we
recommend that opportunities be systematically sought to give greater emphasis to
“nutrition security” within the several on-going activities focused on food security and
international agriculture. A priority is to foster a connection between the nutrition agenda
and the work of the UN System High Level Task Force for the Global Security Crisis,
21
which is stimulating and coordinating actions among the UN system and international
financial institutions.
Opportunities within the HLTF program of work include ensuring that technical support
on nutrition is made available to countries to better measure, report on, and develop
programmatic responses to acute problems of undernutrition linked to high food prices;
promoting the concept that investments intended to increase productivity of smallholder
farmers should also be used to increase the quality of foods, for example through
biofortified crops; and by expanding efforts to establish the global Partnership for Food
Security to encompass a vision of a global Partnership for Food and Nutrition Security.
These ideas could be refined and augmented through consultation with the HLTF
Secretariat. Funders seeking to build a strong bridge between nutrition and the
agricultural sector could explore ways to provide incremental resources to the Secretariat
to support this type of integration.
CONCLUSION
This paper is a modest effort to summarize diverse views about the strengths, weaknesses, and
opportunities for improvement of the international nutrition community. Leaders in the sector
are invited to consider whether this represents a fair assessment of the current complement of
international organizations working on nutrition-related issues, and whether the actions outlined
would be likely to close the gap between the current reality and the ideal vision of greater policy
visibility, better coordination, effective technical support, and significantly more financial
resources. We hope that this paper contributes to a dialogue about these recommendations (or
others that have been proposed) to unify the community into a coherent way forward.
22
Annex 1
Individuals Consulted
1. Marc Van Ameringen, Global Alliance for Improved Nutrition
2. Catherine Bertini, Bill & Melinda Gates Foundation and Syracuse University Maxwell
School of Public Policy
3. Howarth Bouis, Harvest Plus, International Food Policy Research Institute
4. Francesco Branca, Nutrition and Health for Development, WHO
5. Bruce Cogill, UNICEF
6. Frances Davidson, Office of Health and Nutrition, US Agency for International
Development
7. Helene Gayle, CARE
8. Marcia Griffiths, Manoff Group
9. Jean Pierre Habicht, Cornell University
10. Paige Harrigan, Save the Children US
11. Abigail Kelly, Save the Children UK
12. Lawrence Kent, Bill & Melinda Gates Foundation
13. Katharine Kreis, Bill & Melinda Gates Foundation
14. Marti van Liere, Unilever
15. Rahul Malhotra, UK Department for International Development
16. Venkatesh Mannar, Micronutrient Initiative
17. Frances Mason, Save the Children, UK
18. Saul Morris; Gates Foundation, London School of Hygiene and Tropical Medicine
19. Penelope Nestel, University of Southampton, UK
20. Rachel Nugent, Center for Global Development
21. David Pelletier, Cornell University
22. Michael O’Donnell, Save the Children, UK
23. Gretel Pelto, Cornell University
24. Ellen Piwoz, Bill & Melinda Gates Foundation
23
25. Juan A. Rivera, Center for Research in Nutrition and Health, National Institute of Public
Health, Mexico
26. Shireen Khan, PepsiCo
27. Werner Schultink, UNICEF
28. Meera Shekar, World Bank
29. Louise Sserunjogi, GAIN
30. Roy Steiner, Bill & Melinda Gates Foundation
31. Toby Stillman, Save the Children, US
32. Shakuntala Thilsted, Independent
33. Ricardo Uauy, IUNS, Professor of PH/Nutrition, London School of Hygiene and Tropical
Medicine; SCN Working Group Chair
34. Ulrich Villis, Boston Consulting Group
24
Annex 2
Table 1. Illustrative Organizations Active in International Nutrition
Category
Organization
Key Role(s) Related to Nutrition
UNICEF
Program implementation focused on maternal and child health,
Multilateral Agencies
norms and standard setting. Focus on nutrition security,
micronutrients, breastfeeding, and emergency response.
United Nations
Network of food and nutrition professionals. Promotes cooperation
Standing
among UN agencies and partner organizations, including NGOs, in
Committee on
support of community, national, regional, and international efforts to
Nutrition (SCN)
end malnutrition.
World Bank
Project and sector financing to countries with loans on nearcommercial and soft terms. Supports government implementation of
projects and policy reforms with technical assistance from WB staff
and consultants.
World Food
Implementation of emergency response/food aid. Provides logistics
Programme
and support through development programs. Operates school
(WFP)
feeding programs.
World Health
Sets standards, and establishes policies and programs. Biomedical /
Organization
public health focus on reduction of micronutrient malnutrition,
(WHO)
growth assessment and surveillance.
Canadian
Donor with focus on micronutrient and other technical interventions,
International
i.e. vitamin A programming and iodine.
Bilateral Agencies
Development
Agency (CIDA)
United States
Largest bilateral donor; focus on targeted maternal and child health
Agency for
projects, micronutrient interventions.
International
Development
(USAID)
Non-Governmental Organizations
Academy for
Short-term technical assistance, product research and marketing.
25
International
Development
CARE
Technical support. Focus on the delivery of food commodities and
resources during emergencies.
Global Alliance
Support public-private partnerships to address micronutrient
for Improved
deficiencies.
Nutrition
Helen Keller
Intervention delivery; research, and advocacy functions. Focus on
International
nutrition, child survival, and eye health.
Manoff Group
Intervention delivery, communications and behavior centered
programming.
Micronutrient
Intervention delivery and research. Focus on micronutrient and
Initiative
vitamin deficiencies, vitamin A supplements, fortification.
PATH
Development of new diagnostics for micronutrient deficiencies;
innovation in biofortified foods
Category
Organization
Key Role(s) Related to Nutrition
Universities and research institutions
Consultative
Research; alliance of members, partners and 15 international
Group on
agricultural centers. Focus on food security.
International
Agricultural
Research
(CGIAR)
Cornell
Training and research, including basic science, community nutrition,
University
policy development.
Instituto de
Research and program implementation, teaching and training
Investigación
services in health and nutrition. Focus on community health in Peru.
Nutricional
(Lima, Peru)
International
Development of biofortified foods.
Center for
Tropical
26
Agriculture
(CIAT)
International
Scientific research and related activities; supported by CGIAR; focus
Food Policy
on food security and poverty reduction. Implementing HarvestPlus.
Research
Institute (IFPRI)
Johns Hopkins
Research and training in public health nutrition.
University
Bloomberg
School of Public
Health
London School
Research and training in public health nutrition.
of Hygiene and
Tropical
Medicine
Mahidol
Research and policy analysis, training, and consultation.
University,
Thailand
Private Sector
Danone
Grameen Danone partnerships to promote local entrepreneurship in
nutrition.
Unilever
Partnership with WFP to improve the nutrition and health of poor
school-aged children.
Philanthropies
Bill & Melinda
Focus on reducing micronutrient deficiencies and undernutrition in
Gates
vulnerable groups, particularly women & children < 2 years through
Foundation
Global Health program; Global Development program includes
grantmaking to increase quantity and quality of staple foods.
Children’s
Emerging emphasis on nutrition and food security as part of long-
Investment Fund
term development programs.
27